Excessive fat can damage liver, cause cancer – Dr Akande

Dr Kolawole Akande, a consultant gastroenterologist at the University College Hospital (UCH) in Ibadan, in this interview with SADE OGUNTOLA, explains excessive fat in the liver as a dangerous condition not to overlook, as according to him, it could be a red flag for more serious conditions like diabetes, hypertension, abnormal levels of fat and obesity. Excerpts:

Non-alcoholic fatty liver disease is said to be a common condition in Nigeria and a possible cause of a silent organ breakdown. How is that so?

Non-alcoholic fatty liver disease (NAFLD), that’s the old name of the condition. It was changed about two years ago to Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD). It is becoming the most common liver condition all over the world, affecting about 30% of the adult population. In Nigeria, I’m not aware of any community study, but we have people who have looked at the prevalence of this condition among those that have diabetes and/or obesity, with figures ranging from 16 to 46 per cent.

The most accurate method for its diagnosis is liver biopsy, which is a procedure in which we use a needle to take a tiny part of the liver for specialists (pathologists) to look at it under the microscope. But because of the invasive nature of liver biopsy, most people will not subject themselves to it. Commonly, people use abdominal ultrasound, which is good, but it’s not sensitive enough, meaning that abdominal ultrasound may not be able to detect the early form of MASLD.

Most of the studies on fatty liver used abdominal ultrasound for its diagnosis, which means the actual figures may be higher than those found by the studies. So MASLD is a common condition all over the world, and Nigeria is not an exception.

Can the condition be asymptomatic? And if so, how is it often discovered?

So, MASLD is most of the time asymptomatic. Most of the patients don’t even know that they have it. It is often detected when people go for an abdominal ultrasound for something else, and then they look at the liver, and they say, “Oh, you have a fatty liver.” Or sometimes when people do blood tests called liver function tests, and they find out that the tests are abnormal, then the person is asked to do an abdominal ultrasound, and they find out, “Oh, you have a fatty liver.” Rarely, some people with MASLD can have some form of pain in the right upper abdomen, but usually it is asymptomatic.

How dangerous is the condition? Why is it that it initially gives no symptoms?

There are two types of MASLD. There’s one that is just an accumulation of excessive fat in the liver (steatosis). And there’s one that the accumulation is already affecting the liver, causing inflammation of the liver. That’s the one we call steatohepatitis. That one is more dangerous.

Steatotic hepatitis is a marker that the excessive fat in the liver is already damaging the liver. It also has a likelihood of progressing into liver fibrosis and liver cirrhosis and then later, can lead to liver cancer. Some steatosis can regress back to a normal liver; some will remain just fatty liver, and some will progress to liver cirrhosis and/or cancer.

What are the kinds of people who are prone to this MASLD?

The categories of people at risk of MASLD are those who have diabetes mellitus, those who are obese or overweight, those with excessive abnormal lipids in their blood (dyslipidaemia) and those with hypertension (persistently high blood pressure of 140/90 or more). All these four conditions are important cardiovascular diseases.

And as a matter of fact, people think that MASLD is the liver component of the cardiovascular syndrome. The most common cause of death among patients with MASLD is not a liver disease but cardiovascular events like stroke, heart attack and kidney disease. That is why once there is MASLD or NAFLD or excessive fat in the liver that is not due to alcohol, you need to look for things like diabetes, hypertension, dyslipidaemia and obesity to manage them appropriately.

What is the probable age group most affected by MASLD?

Diabetes, hypertension, dyslipidaemia and obesity are conditions that predispose to MASLD, so you will have MASLD more in the age group that is affected by these conditions. These are conditions that occur more in middle age and above. However, childhood obesity is also becoming a problem because of our way of life and diet, and so MASLD is also now occurring in children.

How is it different from other liver diseases?

MASLD is different from other liver diseases like viral hepatitis or alcoholic liver diseases, even though all of them may lead to liver cirrhosis and/or liver cancer if they persist in injuring the liver. MASLD is particularly unique because of its association with cardiovascular factors and because it does not have a specific treatment or drug of choice as we speak.

Which is the most dangerous of these conditions that affect the liver?

All of them are dangerous. In our environment, viral causes, especially hepatitis B, are the most common cause of liver disease. But it is also possible for somebody to have fatty liver and have hepatitis B. Some people have hepatitis and are also taking excessive alcohol. The effect of the two would be much more than the effect of either of them on the liver. So they are all important.

Sadly, in our environment, we have not conquered the infectious cause of liver disease, and we are now acquiring the non-infectious causes like MASLD because of our ways of life, including sedentary lifestyles and intake of food with high glucose content.

How is it diagnosed and treated?

The most accurate form of diagnosis for MASLD is liver biopsy, a procedure in which we use a needle to take a small part of the liver for a special test called histology by our laboratory colleagues (pathologists). But that is an invasive procedure that most people will not want to have.

There’s also another method, which we call transient elastography. The common one is what we call a FibroScan, which is a machine with a special probe that can detect fat in the liver. There’s also a form of medical imaging (MRI) that can be used to diagnose it. However, abdominal ultrasound is the most common method of diagnosis of a fatty liver, although it may not detect the earliest form of MASLD.

Is MASLD treatable?

Yes and no. Yes, because one can treat whatever is causing it. So, if somebody has MASLD we need to find out if he’s diabetic and then treat the diabetes. If he’s obese, we ask him to lose weight. If he has dyslipidaemia, we treat it. Treatment of the conditions associated with MASLD can slow down, or sometimes reverse, the MASLD.

However, the most consistent treatment is diet and exercise that lead to weight loss. If the patient can lose at least 10 per cent of his weight over time, the MASLD could be reversed or at least slowed down. But there is no specific drug for the treatment of MASLD as we speak. Currently, researchers are looking at many specific drugs that can treat MASLD, and we hope for a breakthrough soon.

What is the prognosis, therefore, for individuals with this condition?

The prognosis depends on how advanced the MASLD is at the time of the diagnosis. The prognosis with just fat accumulation (steatosis) is better than when it has progressed to steatohepatitis, which makes the occurrence of a more severe liver disease more likely. The prognosis of MASLD also tends to be worse in those with diabetes than in those who do not have diabetes.

So, how does this condition predispose to cardiovascular conditions like heart disease, diabetes and hypertension?

So, it’s not as if MASLD predisposes to diabetes, hypertension or the other cardiovascular conditions. The fact is that they are associates. Where you have one, you may also find the others most likely.

It is also established that the most common causes of brain disorders like stroke, as well as conditions like heart attack and heart failure, are things like hypertension and diabetes. The most common cause of death among people with MASLD is not a liver disease but cardiovascular problems.

It is for this reason that once you see excessive fat in the liver and the person is not taking alcohol, you must quickly look for all these other things and begin to treat them. They are clusters of friends or associates.

What are the current research topics on MASLD that are being conducted, and what is the potential for a cure in the years to come?

MASLD is an area of intense research worldwide because, as I said, it is a common liver disease. Researchers are busy looking at many aspects of MASLD, including molecules that can detect MASLD early, those that can predict who will progress to a more severe form of liver disease and who will not progress, and of course, specific treatment for MASLD, which is not available now.

Any word of caution for individuals with MASLD?

Anyone diagnosed with fatty liver should go to the hospital for proper evaluation of the liver, causes of the MASLD and their treatment if found.

Are there challenges you face in managing MASLD?

Yes. Because MASLD is largely asymptomatic, people tend not to take it seriously, especially because healthcare financing is largely out of pocket in Nigeria. People might question why they are spending too much on a condition that is not giving them any symptom at all. The scarcity of healthcare professionals in our hospital is another challenge.